Personal Insurance Homeowner Fact Finder

Date*
MM slash DD slash YYYY
How did you hear about Avery Insurance?
Primary Insurance Holder Information
Name*
First Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
How long have you been at your current address?*
How long have you been at your current address?
Please enter a number from 0 to 100.
Months*
Phone Number*
Untitled*
- Home
- Cell
- Business
Email*
Marital Status
DOB*
MM slash DD slash YYYY
Occupation
Secondary Insurance Holder (if applicable)
Name (Secondary)
First Last
Phone
Untitled
- Home
- Cell
- Business
Email
DOB
MM slash DD slash YYYY
Occupation
Marital Status
Property Information
Property Location (if different from mailing address)
Street Address Address Line 2 City State ZIP Code
How long have you owned this property?
How long have you owned this property?
Please enter a number from 0 to 100.
Months
If less than 3 years please provide previous address:*
Is this a new purchase?
- Yes
- No
What is the closing date:
MM slash DD slash YYYY
Is there a mortgage?
- Yes
- No
What is the bank name?
What is the bank payor?
What is the bank address?
What is the usage of the property?*
Year Built*
Style
Number of stories:
Total square feet*
Value*
Type of construction*
Other*
Type of heating/fuel*
Location of oil tank (if applicable)
Type of electrical system*
Number of amps (if applicable)
Approximate year of updates on the systems below (for buildings 20 years and older)
Heating
Plumbing
Wiring
Roofing
If the house was built prior to 1930, what are the wall partitions constructed of?
Does your kitchen have any custom features? (i.e. granite, customer cabinets, high end appliances, etc.)
- Yes
- No
Please list these features:
How many bathrooms?
Any custom bathroom features?
- Yes
- No
Please list these features:
What is the roof type?*
What is the siding material?*
Do you have a basement?
- Yes
- No
Please check all that apply.
- Finished Basement
- Partially Finished
- Walkout
- Drain
- Sump Pump
Do you have a garage?
- Yes
- No
What type of garage?
- Attached
- Detached
Do you have any outbuildings or other structures?
- Yes
- No
Please list:
Is there a fire hydrant within 1,000 ft of your home?
- Yes
- No
Is there a central burglar or fire alarm?
- Yes
- No
What kind of alarm?
Additional Information
Pets?*
- Yes
- No
Please list the types and the breed(s):*
Any bite history?*
- Yes
- No
Please describe:*
Any obedience training?*
- Yes
- No
Please describe:*
Pool?*
- Yes
- No
Please check all that apply.*
- Above ground
- Inground
- Fenced
- Slide
- Diving board
Trampoline?*
- Yes
- No
Is it enclosed?*
- Yes
- No
Is there any type of business conducted in your home?
- Yes
- No
Please describe:
Do you have customers come to your home?
- Yes
- No
Please describe:
Do you employ any domestic staff?
- Yes
- No
Please describe:
Do you have any special items (such as jewelry, fine arts or musical instruments) that you would like to insure separately?
- Yes
- No
Please provide a brief description and approximate value:
Do you belong to a homeowner or condo association?
- Yes
- No
Which association(s)?
Do you currently have a personal umbrella/excess liability coverage?
- Yes
- No
What are your current insurance limits?
Any prior losses/claims? (From current home or other locations.)*
- Yes
- No
Please provide date and description:*
Has your insurance been canceled or non-renewed in the past 3 years?*
- Yes
- No
Please describe:*
Any bankruptcy(s) in the past 5 years?*
- Yes
- No
Please describe:*
Would you like any information on the following? Oftentimes, combining different lines of business with one insurance company result in premium savings
- Auto insurance
- Boat insurance
- Personal insurance
- Umbrella insurance
- Excess liability
- Recreational vehicle insurance
- Earthquake insurance
- Flood insurance
- Business
- Life
- Health
- Other
Other
Who is your current insurance carrier?
Policy expiration date:
MM slash DD slash YYYY
Additional comments:

Coverage Request Contact Avery Visit Our Offices

Contact Avery Insurance Today at 1.800.759.7579

Contact Request a Quote

Personal
Business
About
Contact Us

News & Blog
Events
Claims
Privacy Policy

Visit us on facebook Visit us on linkedin Visit us on twitter Visit us on instagram Visit us on youtube

Wolfeboro

21 S Main Street
Wolfeboro NH 03894
603.569.2515

Portsmouth

7 Islington St #102
Portsmouth NH 03801
603.766.3733

New Orleans

836 Walker Street
New Orleans LA 70124
800.759.7579